Provider Demographics
NPI:1194147637
Name:FAYETTE MEDICAL CENTER-CRNA
Entity type:Organization
Organization Name:FAYETTE MEDICAL CENTER-CRNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-932-1104
Mailing Address - Street 1:1653 TEMPLE AVE N
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555-1314
Mailing Address - Country:US
Mailing Address - Phone:205-923-5966
Mailing Address - Fax:205-932-1260
Practice Address - Street 1:1653 TEMPLE AVE N
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1314
Practice Address - Country:US
Practice Address - Phone:205-923-5966
Practice Address - Fax:205-932-1260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102G704766OtherMEDICARE ID